Definition of Nursing Documentation

Definition

Documentation

It is the process of communicating in written form about essential fact. Records and reports are essential components of documentation.

Records

It is a written communication that permanently document the information relevant to a client’s health care management. (Sr.Mary Lucita)

Record is the valuable sources of data for all members of the health care team.

Reports

Reports may be oral or written form of documentation.

Report is an oral, written or computer based communication intended to convey information to other. (E. Angelina Jolie)